11/10/2014 1 Common Problems in Urology Supanut Lumbiganon, MD. Outline 1. Renal Colic 2. Urinary Retention 3. Acute Scrotum Renal colic O Sudden increase of pressure in the urinary tract and the ureteral wall. O Pain comes in waves and does not decrease if you change positions. O One of the most painful experiences, similar to giving birth “The most common urologic emergency”
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11/10/2014
1
Common Problems in
Urology
Supanut Lumbiganon, MD.
Outline
1. Renal Colic
2. Urinary Retention
3. Acute Scrotum
Renal colic
O Sudden increase of
pressure in the urinary
tract and the ureteral wall.
O Pain comes in waves and
does not decrease if you
change positions.
O One of the most painful
experiences, similar to giving birth
“The most common urologic emergency”
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Typical characteristic O Very sudden onset
O Colicky in nature
O Radiates to the groin as the stone passes
into the lower ureter.
O May change in location, from the flank to
the groin
O The patient cannot get comfortable, and
may roll around in agony.
O Associated with nausea / Vomiting
Renal colic ?? Really ??
Diverticula disease AAA
Differential diagnosis
O Acute appendicitis
O Ovarian pathology Diverticulitis
O Ectopic pregnancy
O Bowel obstruction
O Abdominal aortic aneurysms O Testicular torsion
O Burst peptic ulcer
O Pneumonia
O Myocardial infarction
O Inflammatory bowel disease (Crohn‟s, ulcerative colitis)
Investigations
O History + Physical examinations
O UA, Urine pregnancy test
O CBC
O Imaging
O Film KUB
O U/S abdomen
O IVP
O CT KUB +/- Abdomen
Loin pain – pyrexia and stone
A possible stone on a KUB necessitates an IVU for anatomical delineation..... or a non-contrast CT
PUJ stone
PUJ stone
IVU does give you information about function
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Dilated PC system
Non-function or pyrexia demand a nephrostomy
Acute Management of Ureteric Stones
Pain relief
O NSAIDs
O Intramuscular or intravenous injection, by
mouth, or per rectum
O +/- Opiate analgesics (pethidine or morphine).
Hyper hydration
„watchful waiting‟ with analgesic supplements
O 95% of stones measuring 5mm or less pass
spontaneously
Indications for Intervention to Relieve Obstruction and/or Remove the Stone
O Pain that fails to respond to analgesics.
O Associated fever, pyonephrosis
O Renal function is impaired because of the
stone
O Obstruction unrelieved for >4 weeks
O Personal or occupational reasons
Treatment of the Stone
O Temporary relief of the obstruction:
O Insertion of a JJ stent or percutaneous
nephrostomy tube.
O Definitive treatment of a ureteric stone:
O ESWL.
O PCNL
O Ureteroscopy
O Open Surgery: very limited.
Urinary retention
O Acute Urinary retention
O Chronic Urinary retention
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Acute Urinary retention
O Painful inability to void, with relief of pain following drainage of the bladder by catheterization.
O Pathophysiology :
O Increased urethral resistance, i.e., bladder outlet obstruction (BOO)
O Low bladder pressure, i.e., impaired bladder contractility
O Interruption of sensory or motor innervations of the bladder
Acute urinary retention
O Causes : O Men:
O Benign prostatic enlargement
O Carcinoma of the prostate
O Urethral stricture
O Prostatic abscess
O Women
O Pelvic prolapse (cystocoele, rectocoele, uterine)
O Urethral stricture;
O Urethral diverticulum;
O Post surgery for „stress‟ incontinence
O pelvic masses (e.g., ovarian masses)
Acute urinary retention
O Both Sex O Haematuria leading to clot retention
O Drugs
O Pain
O Sacral nerve compression or damage(cauda equina compression )
O Radical pelvic surgery
O Pelvic fracture rupturing the urethra
O Multiple sclerosis
O Transverse myelitis
O Diabetic cystopathy
O Damage to dorsal columns of spinal cord causing loss of bladder sensation (tabes dorsalis, pernicious anaemia).
Acute urinary retention
O Initial Management :
O Urethral catheterization
O Suprapubic catheter ( SPC)
O Late Management:
O Treating the underlying cause
Chronic urinary retention
O Obstruction develops slowly, the bladder is
distended (stretched) very gradually over
weeks/months, so pain is not a feature .
O Presentation:
O Urinary dribbling
O Overflow incontinence
O Palpable lower suprapubic mass
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Chronic urinary retention
O Usually associated with
O Reduced renal function.
O Upper tract dilatation
O Treatment is directed to renal support.
O Bladder drainage under slow rate to avoid
sudden decompression> hematuria.
O Treatment of cause.
Acute Scrotum
O Emergency situation requiring prompt evaluation,
differential diagnosis, and potentially immediate
surgical exploration
Differential Diagnosis
1. Torsion of the
Spermatic Cord
O Most serious.
2. Torsion of the
Testicular and
Epididymal
Appendages.
3. Epididymitis.
O Most common
Torsion of the Spermatic Cord (Intravaginal)
O True surgical emergency of the highest order
O Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours
O Testicular salvage ↓ as duration of torsion↑
Presentation:
O Acute onset of scrotal pain.
O Majority with history of prior episodes of severe, self-limited scrotal pain and swelling.
O N/V
O Referred to the ipsilateral lower quadrant of the abdomen.
O Dysuria and other bladder symptoms are usually absent.
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Testicular torsion
3
Physical examination:
• The affected testis is high-
riding Transverse orientation.
• Acute hydrocele or massive
scrotal edema
• Cremasteric reflex is absent.
• Tender larger than other side.
• Prehns sign -ve.
O Manual detortion.
Signs O Prehn +ve = decrease pain
when elevate testis suspected epididymitis
O Dresner‟s sign = dark
blue spot at scrotal sac suspected tortion testicular appendix
O Robinowitz‟s signs = absent of cremasteric reflex suspected testicular tortion
Adjunctive tests:
O To aid in differential diagnosis of the acute
scrotum.
O To confirm the absence of torsion of the
cord.
O Doppler examination of the cord and testis
O High false-positive and false-negative results
O Assessment of anatomy and determining the
presence or absence of blood flow.
O Sensitivity: 88.9% specificity of 98.8%
O Operator dependent.
Color Doppler ultrasound:
O Swollen
O Hydrocele
O Absent blood flow
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Radionuclide imaging :
O Assessment of testicular blood flow.
O PPV of 75%, a sensitivity of 90%, and a
specificity of 89%.
O False impression from hyperemia of scrotal
wall.
O Not helpful in Hydrocele and Hematoma
Torsion of the Spermatic Cord…
Surgical exploration: O A median raphe scrotal or a transverse incision.
O Affected side to be examined first
O The cord should be detorsed.
O Testes with marginal viability should be placed in
warm sponges and re-examined after few minutes.
O A necrotic testis should be removed
O If the testis is to be preserved, placed into the
dartos pouch (suture fixation)
O The contralateral testis must be fixed to prevent
subsequent torsion.
1
2
3
4
Minor twist-viable
Major twist- ? viable
Major twist-viable!
Major twist-necrotic
Torsion of the Spermatic Cord…
TORSION
O In the seventeenth century, Frr Jacques gained great fame as a
`stone-cutter` or `lithotomist`. He travelled through Europe,
practising a bladder-stone removal technique that became the golden standard for a long time.
Lithotomy Position
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